People for and against the Affordable Care Act protest in front of the U.S. Supreme Court.

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The historic 5-4 decision will affect the way Americans receive and pay for their personal medical care in the future. It upholds the individual mandate that most Americans get health insurance or pay a penalty — and it was the penalty, or tax, that ultimately saved the law.

Chief Justice John Roberts announced the decision that allows the law to go forward with its aim of covering more than 30 million uninsured Americans. He argued that the mandate is constitutional only because the penalty "functions like a tax" and is therefore allowed under Congress' taxing power.

"Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness," Roberts wrote.

"The majority rewrites the statute Congress wrote. … What Congress called a penalty, the court calls a tax," Kennedy said. "The Affordable Care Act now must operate as the court has revised it, not as Congress designed it."

Reactions: Health care ruling

President Obama, speaking from the White House after the decision, said, "Whatever the politics, today was a victory for people all over this country whose lives will be more secure because of this law and the Supreme Court's decision to uphold it.

"It should be pretty clear by now that I didn't do this because it's good politics," Obama said. "I did it because I believed it was good for the country."

Roberts — a conservative appointed by President George W. Bush— provided the key vote to preserve the landmark health care law, which figures to be a major issue in Obama's re-election bid against Republican opponent Mitt Romney.

Romney immediately vowed to make repeal of the law a major part of his campaign, calling it too expensive, too much government, and too much of a burden for job creators.

Impact of health care ruling

"Obamacare was bad policy yesterday," Romney said Thursday. "It's bad policy today. If we want to replace Obamacare, we need to replace Obama."

The government had argued that Congress had the authority to pass the individual mandate as part of its power to regulate interstate commerce; the court disagreed with that logic, but preserved the mandate because it said the fine amounts to a tax that is within Congress' constitutional taxing powers.

As lawyers examined the details of the various opinions, political analysts quickly predicted at least a short-term political boost for Obama.

He noted, however, that the ruling allows Romney "to continue campaigning against the law and promising to repeal it."

Yale law professor Akhil Reed Amar said the decision is a "huge win for Barack Obama and John Roberts." Amar said Roberts managed to save the health care law while still creating significant new limits on the federal government's authority.

"On the bottom-line issue, he voted with appointees of the other party, and he did so even as he moved the case law to the right by narrowing the scope of Congress' commerce power and accepting conservative principles," he said.

House Majority Leader Eric Cantor, R-Va., announced that the GOP-run House will vote July 11 on full repeal of the health care law — more of a symbolic gesture because the Democratic-run Senate will not follow suit.

House Budget Committee Chairman Paul Ryan, R-Wis., acknowledged that the election will be a determining factor for the law's fate and the GOP's ability to overturn it.

"It's up to the American people in the next election and their representatives to determine the fate of this law," he said.

Other congressional Republicans vowed to step up efforts to repeal what they call "Obamacare," should they win control of Congress in the November elections.

"The president's health care law is hurting our economy by driving up health costs and making it harder for small businesses to hire," said House Speaker John Boehner, R-Ohio. "Today's ruling underscores the urgency of repealing this harmful law in its entirety."

Conservative groups plan to launch major advertising efforts to attack the law. American For Prosperity, which already has spent $12 million to criticize Obama's energy policies, plans an $8.2 million ad blitz in response to the ruling.

The ads will run in a dozen presidential battleground states: Colorado, Florida, Iowa, Minnesota, Nevada, New Hampshire, New Mexico, North Carolina, Ohio, Pennsylvania, Virginia, Wisconsin.

"Americans for Prosperity is deeply disappointed by the Supreme Court's decision to uphold a law that most Americans believed to be unconstitutional and wanted to see repealed," the group's president Tim Phillips said in statement. "As a result, unless Congress steps in and repeals this legislation, health care costs for most Americans will go up while the quality of health care goes down as Washington politicians ramp up yet another massive new bureaucracy. The Court got it wrong, and now Congress must step in."

The law's individual mandate had been the key question for the court.

Critics called the requirement an unconstitutional overreach by Congress and the Obama administration; supporters said it is necessary to finance the health care law.

The "tax," as Roberts called it, is a penalty for not buying health insurance. In 2016, the first year it will be fully in effect, it amounts to $695 for an individual and $2,085 for a family, or 2.5% of household income - whichever is larger.

The decision showed once again that the high court isn't shy about weighing in on major legislative issues and influencing the political balance of power. Since its 5-4 decision affirming George W. Bush's election as president in December 2000, the justices have tackled issues of huge importance, ranging from affirmative action to campaign finance, with equal aplomb.

In this case, the decision will have an immediate and major impact on the nation's health care system. Health care for millions of Americans will be affected — coverage for some, premiums for others. Doctors, hospitals, drug makers, insurers and employers large and small all will feel the impact.

The actions of both federal and state governments also will be affected. States — some of which have moved ahead with the health care overhaul while others have held back — now have decisions to make.

While the individual mandate requiring most Americans to have health insurance remain 18 months away from implementation, many other provisions already have gone into effect, such as reductions in seniors' prescription drug costs, help for children and some adults with pre-existing conditions, and allowing children up to age 26 to remain on their parents' policies.

The court decision represents "the beginning, not the end, of the big debate on health care reform," said Bill McCollum, the former Florida attorney general who filed the first lawsuit on the day the law was signed 27 months ago.

George Mason University law professor Ilya Somin, who wrote a brief opposing the health care law, said other parts of the court's decision - particularly the justices' insistence that the government could not cut off all Medicaid funding to states that want to opt out of the health law - could provide ammunition for more challenges to the federal government's power in the future.

"It's clear we will continue to be fighting these issues about the limits of federal power," he said.

Not since the court confirmed Bush's election — before 9/11, Afghanistan and Iraq, Wall Street's dive and Obama's rise — has one case carried such sweeping implications for nearly every American.

Passed by Democrats along strictly partisan lines, the law is designed to extend health coverage to some 32 million uninsured people, ban insurers from discriminating against those with expensive ailments, and require nearly all Americans to buy insurance or pay penalties.

Its passage on March 23, 2010, marked the culmination of an effort by Democrats to overhaul the nation's health care system that dates back to Harry Truman's presidency. The most recent effort by President Bill Clinton in 1994, spearheaded at the time by First Lady Hillary Rodham Clinton, fell victim to Republican opposition. Since then, lesser changes have been enacted, including creation of a separate Children's Health Insurance Program in the states.

The new law was challenged in a Florida court the day it was passed, and several other lawsuits made their way through district and appellate courts. A majority, but not all, of those courts upheld the law.

The principal challengers were a coalition of 26 states and the National Federation of Independent Business. Beyond them, more than 130 briefs in support or opposition — a modern record, surpassing two Supreme Court affirmative action cases in 2003 — were filed by organizations ranging from the seniors group AARP to the Young Invincibles, representing young adults.

During three days of dramatic oral arguments in March, attorneys for the plaintiffs, led by former U.S. solicitor general Paul Clement, argued that the government never has required Americans to enter into commerce and warned that such a mandate could lead to more in the future. If this is allowed, they said, what couldn't the government do?

The current solicitor general, Donald Verrilli, argued that Congress has the power to regulate interstate commerce. The mandate would do that by regulating the financing of health care, which represents 18% of the nation's economy. He argued that the mandate was required in order to carry out the changes in the insurance market, such as guaranteeing coverage to people with pre-existing conditions.

Yet even the government contended in court that if the mandate was struck down, it should take at least some of the most popular provisions with it. That would include guaranteed coverage for people with pre-existing conditions and limits on premiums for those with expensive ailments — changes the government said could not be paid for unless millions more people bought insurance.

The states and business group challenging the law argued that the mandate wasn't "severable" at all — if it was struck down, the entire law should fall. During three days of oral arguments in late March, several of the court's conservative justices appeared to agree with that argument.

In addition, the states argued that the expansion of Medicaid with initial 100% federal funding was "coercive," by luring states into an offer they could not refuse. They said it also would pull other people into Medicaid who already qualify but have not enrolled and would require certain treatments, all at a cost states cannot afford.

About the only thing both sides agreed on was that an obscure 1867 law, the Anti-Injunction Act, should not prevent the justices from rendering their verdict before the entire law was in effect.

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